Rabies kills 60,000 people a year, despite the development of a vaccine more than a century ago. As part of our focus on rabies, and to mark World Rabies day on 28 September, we spoke with Felix Lankester, Assistant Professor at Washington State University’s Paul G. Allen School for Global Animal Health & Director of the Serengeti Health Initiative. A man who’s at the frontline of efforts to eradicate the disease in Africa.
Based in Tanzania, Felix spoke to us about the challenge of delivering a rabies eradication campaign and working with the Serengeti Health Initiative – a rabies control project that works with local people in East Africa to ensure widespread vaccination of around 120,000 dogs a year.
What does tackling rabies mean to you, as an individual?
As a veterinarian, there are very few human diseases that you will work with that will have such an impact on public health.
It’s incredibly rewarding when you host these vaccination campaigns, which are very complicated to run, expensive and logistically challenging. They're also extremely tiring for the teams participating.
But when you see the level of enthusiasm that these communities have for the vaccination campaigns, you get a great sense of a job well done when hundreds and hundreds of people are lined up with their dogs on a particular day.
On the flipside, one of the hardest things one could witness is someone lying in a hospital bed suffering from rabies; it’s very, very sad and distressing. When there's nothing that the medical staff can do to save that person, it must be incredibly harrowing for the patient, their family and the medical team to endure.
What does a typical day look like?
For those living in villages in the south and west of the Serengeti ecosystem, we can carry out a "central point" vaccination strategy, targeting a village per day. The day before vaccination, we’ll advertise with loudspeakers and put up posters in prominent positions.
The following day, at around 8am, the team arrives with refrigerated vaccinations. They pick a point in the village, usually under a tree where there is some shade, and people then bring their dogs to this temporary clinic.
A long line develops as all these owners and their dogs wait for their inoculations. Once the owner reaches the front, the name of the dog is taken, the owner gets a vaccination card for each dog and then they move to the vaccination area where they are inoculated again rabies, distemper and parvovirus.
In contrast to this, when we are vaccinating in the more remote pastoral areas to the east of the Serengeti where people’s homes (called ‘bomas’) are more spread out we carry out a boma to boma strategy which involves the vaccination team walking from house to house delivering vaccination on foot. As you can imagine this is very time consuming and tiring but it’s really the only effective way of reaching a high proportion of the local dogs.
Could you describe the Serengeti Health Initiative (SHI)? What are the primary activities, objectives and partners?
SHI’s responsible for the vaccination of around 120 000 dogs per year but the number of dogs that our team vaccinates themselves is around 45 000. The rest are vaccinated by government district veterinary offices, usually with vaccines that we distribute to be used in those government district offices.
Our work is funded by Washington State University and Lincoln Park Zoo, while the vaccines are donated by MSD Animal Health.
How do you get communities involved and excited?
There are a few things we do to help improve involvement. We would like to hold our vaccinations within the school holiday time because it is the children who are predominantly given the responsibility of bringing the dogs. However, there are too many villages in the area that we target to only be active during the relatively short school holidays, so we have to vaccinate throughout the year. But definitely, if you are carrying out constant vaccination activity then it is wise to target during the school holidays.
We tried something new about two or three years ago, which brought great results. We carried out a randomised controlled trial to determine what impact offering incentives to the villagers would have on the number of dogs brought in for vaccination. We offered the local children little rubber wristbands to wear, carrying messages such as, "my dog is rabies free". We divided the villages up between those being offered the gift of the wristbands and those who weren’t and then monitored the turnout to see how many dogs were vaccinated in each village.
We compared the number of dogs vaccinated to the previous year found that there was a significant increase in take up in villages that received the gifts. It makes sense. Obviously, the children were excited about receiving wristbands and they then told their friends who then brought their dogs and this resulted in more dogs being vaccinated.
What are the main challenges to delivering successful eradication programmes?
People in sub-Saharan Africa know what rabies is often because they've seen or heard about people dying of rabies in their communities and so they're very supportive of the work we do. They also tend to have no fear of bringing their dogs in for a vaccination. We've now been vaccinating in some villages for 10 - 15 years and the incidence of rabies in those villages has been reduced to pretty much zero.
As a result of our success, there is some concern that there may be fatigue in those areas because the villagers no longer perceive rabies to be a risk, so they may not see the value in bringing their dogs in for vaccination. In this situation, we will need to enhance our education output, reminding people of the importance of vaccinating their dogs and discussing with village leaders the importance of rabies vaccination.
The community leaders in the villages have a very important role to play in encouraging the community as a whole to support these interventions. An interesting and important example is in the North-Eastern Serengeti, where following one campaign a number of dogs in one particular village became infected with sarcoptic mange. We aren’t sure whether this happened as a result of the dogs all coming together for vaccination but since then, we’ve always had a problem vaccinating in that village because the villagers are very suspicious that the vaccination will make their dog get sick or develop mange. So the community leaders have a key role to play in reminding the community about the public health risk of rabies and encouraging them to keep bringing their dogs in for vaccination.
What are some of your biggest frustrations?
There can be many frustrations. The weather being one. When you have a day of bad weather and it causes a low turnout at a vaccination site it’s incredibly frustrating because you know that that is the only chance that that village has for that year to receive vaccinations. Our research has shown that low vaccination coverage in a few small areas or pockets within a region will directly increase the time it takes to eliminate rabies within the region as a whole.
It's also incredibly sad when you hear about children dying of rabies. Or indeed, something that happened last year, when a child that was bitten by a rabid animal was given the wrong post-exposure vaccination. A couple of children in the eastern area of the Serengeti were bitten by a rabid hyena and were given an anti-tetanus vaccination instead of the rabies vaccination. Those children tragically died. Cases like this exemplify the frustrations and the difficulties that families in the remote parts of sub-Saharan Africa face when they suspect that a rabid dog has bitten their children.
Parents of children who fear their child may have been bitten by a suspect rabid animal face a very difficult dilemma. First, they have to decide whether or not the dog was rabid. Its not always easy to tell the difference between an aggressive dog and a rabid dog. If the parents decide that the dog was rabid, they've then got to try to locate the five injections required to protect their child, at a cost up to $100 – that can be as much as three month's salary for people working in these areas. $100 is a huge sum to pay based on the assumption that the dog was rabid. If that dog is subsequently found to not be rabid and continues to live a healthy life then they know they've wasted their money. The flip side of this is when parents make the tragic error of deciding that the dog was not rabid, when in fact it was. In this case the child will end up with rabies and will die.
Why do you think rabies is still such a problem today, despite there being an effective vaccination available for over a century?
When I talk to people about rabies, the first thing I often get asked is, "how many people are dying of rabies?" And as soon as I say, "Well, around 60 000 people a year", without fail, people are amazed. They all say, "Wow, that's so many people. I didn't know that this was an issue and certainly not in those numbers."
When you compare rabies to other diseases that receive huge amounts of international funding, such as Ebola and Avian Influenza, and then you compare the fatality rates of those diseases with rabies it quickly becomes clear that there is a distinct imbalance.
Diseases like Ebola have much lower numbers of human fatalities each year than rabies - 60 000 annually for rabies compared to 11 000 people who died from the recent Ebola outbreak. If you then compare the amount of money that the WHO invested to fight that specific outbreak compared to what rabies eradication has received in the last ten years, the figures don’t add up.
Frequently other diseases come to the fore and rabies is again put on the backburner. However, when you consider other metrics such as whether effective vaccines are available, whether we can target the reservoir, whether we can actually make an impact in a cost-effective manner, then rabies is actually a very good disease to target. Rabies eradication adds up – a domestic animal reservoir host and an effective vaccine. We could make a big difference with a very moderate financial investment.
Can we really meet our 2030 target?
I think if there was a significant uptick in political will and financial commitment, on a global scale then yes, we could get there. Currently there isn’t either the necessary funding or the political will across the countries where rabies remains endemic. We're talking West Africa, Central Africa, Southern Africa, Eastern Africa, Northern Africa, and Asia. It’s in those areas that international support is need support. We just have to look at what's happened in South America, where rabies eradication has been hugely successful, to know that it is possible.
We are though beginning to see a groundswell of momentum, especially in East Africa, in developing national campaign strategies, but more needs to be done, and national strategies cost a lot of money. To take Tanzania as an example, they've done really well developing a strategy but the next step, funding the work, will be key.
Importantly, I don't think it matters if you set targets and miss them. In South America they set ambitious targets but had to reset them several times. That's fine. A target can be moved, it’s really in place to help catalyse a response. The important thing for rabies eradication is that we’ve set 2030 as something to work towards, and hopefully that will result in a more joined up international focus on eradication.
Are there ways that an average person in a country like the U.S or UK can support ending rabies by 2030?
We’re already actively trying to establish programmes in the West to support eradication. Especially in the United States. In Washington, veterinary clinics can currently sign up to a support programme whereby for every dog that is brought into that clinic, and is vaccinated against rabies, the clinic and/or the dog owners donate one dollar towards our programme. To date we’ve set up approximately 30 clinics.
The programme provides a consistent funding stream that is really useful to us and enables us to fund the vaccination programmes that we carry out in East Africa. And raising awareness in the United States is important. If people are vaccinating their dogs they need to be aware of what's happening on the other side of the planet.
One dollar for every dog that gets vaccinated can make a huge difference - it's like crowd-funding for rabies. We need to develop more of these novel fund raising schemes and to encourage high levels of international investment otherwise rabies will continue to kill tens of thousands of people each year, needlessly.